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Sabato Ems Studentlecture


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Sabato Ems Studentlecture

  1. 1. Emergency Medical Services Pre-Hospital Care Joseph Sabato, Jr, MD Assistant Professor of Emergency Medicine Director of Special Operations Mary Tang, MD, MPH, PGY-3 Robert Williams, MD, PGY-3
  2. 2. 1966 National Highway Safety Act Authorized the US Department of Transportation (DOT) for prehospital medical services to fund: „ Ambulances „ Equipment „ Communications „ Training programs
  3. 3. Emergency Medical Services Systems Act of 1973 (public law 93-154) „ Funded and authorized the Department of Health, Education and Welfare to develop EMS throughout the country.
  4. 4. Public Law 93-154 Identified the following 15 components as essential to an EMS system: „ Communications „ Transfer of care „ Training „ Consumer participation „ Manpower „ Public education „ Mutual aid „ Public safety agencies „ Transportation „ Standard medical records „ Accessibility „ Independent review „ Facilities and evaluation „ Critical care units „ Disaster linkage
  5. 5. „ 911 Emergency telephone number ‚ essential front door of the EMS system „ Enhanced 911 (E-911) equipment ‚ provides automatic number and location identification
  6. 6. Emergency Medical Dispatch (EMD) „ Based on the principle that good information gathering during the dispatch phase of an emergency can better prepare responding EMS providers to deal with the situation at the scene. „ Deliver basic emergency care instruction to people on the scene. „ Prioritize request for emergency medical assistance. „ Ensure only appropriate agencies or prehospital providers are dispatched.
  7. 7. Emergency Medical Dispatch (cont’d) May be carried out by a variety of agencies, including: „ Law enforcement agency (LEA) „ EMS agency „ Separate public safety dispatch center
  8. 8. Why is 911 better than dialing “0” ? 1st: Additional call and routing process, which takes precious time. 2nd: The caller may not be connected with the correct jurisdiction or service that he needs.
  9. 9. Training Community education „ First aid „ Child safety „ EMS system access „ Cardiopulmonary resuscitation (CPR)
  10. 10. Dual-response System „ First responders (FRs) followed by ambulance personnel. „ FRs: Firefighters, police, park rangers, or citizen volunteers. „ Emergency Medical Technician (EMT): EMT basic (EMT-B) - CPR, AED, extrication, immobilization EMT intermediate (EMT-I) - IV access, PASG EMT paramedic (EMT-P) - Intubation/RSI, EKG, synchronized cardioversion, manual defibrillation, & drug therapy
  11. 11. Public interest and participation: Key ingredients in any EMS system! „ Urban areas: Public safety and ambulance personnel. „ Rural or wilderness areas: Volunteers, park rangers, or ski patrols.
  12. 12. Mutual Aid Agreements EMS services have agreements with neighboring jurisdictions so that uninterrupted emergency care is available when local agencies are overwhelmed and/or unable to provide services.
  13. 13. Mutual Aid Agreements
  14. 14. Mutual Aid Agreements
  15. 15. Transportation „ Ground ambulances „ Provide most EMS transportation. „ The most important aspect of ambulance design is that the attendants must be able to provide airway and ventilatory support while safely transporting the patient. „ Air transport Helicopter (Rotor-wing) Airplane (Fixed-wing)
  16. 16. Access to Care „ A successful EMS system ensures that all individuals have access to emergency care regardless of their ability to pay or type of insurance coverage „ Emergency physicians must serve as the patients’ advocate!!
  17. 17. FACILITIES General: Shandstastic! „ Transport to the closest appropriate hospital. ‚ If multiple hospitals within the same transport time: patient’s choice. „ Specialized receiving facilities „ Higher level of care warranted ƒ Transport to that institution (by passing closer hospitals). • i.e. trauma, burn, stroke or angioplasty center
  18. 18. Critical Care Units (CCU’s) Tertiary care facilities should be identified by every EMS system to provide specialty care that is not available in typical community hospitals. Most common reasons for tertiary care emergency transfer: „ Trauma „ High-risk obstetrics „ Cardiac care „ Burns „ Neonatal intensive care „ Spinal cord injury „ Neurosurgery „ Pediatric Specialty Hospitals
  19. 19. Transfer of Care „ Must be made with maximum safety for the patient!
  20. 20. Consumer Participation „ Laypersons should be represented on EMS councils. „ Two important components of a successful EMS system: Lay public first aid training Implementation of a 911 system
  21. 21. Public Information and Education „ In designing a public information program, the EMS council’s goal should be for the public: 3. Understand how the community stands to benefit from an excellent EMS system. 4. Be prepared to render first aid care. 5. Know how to access the EMS system quickly. 6. Understand that patients may not be delivered to the hospital of their choice under life- threatening conditions.
  22. 22. Public Safety Agencies „ Strong ties with police and fire departments „ Often provide first-response service because their personnel are often the first on the scene of an emergency. I.e., police carrying oxygen and automatic defibrillators
  23. 23. Standardization of Patients’ Records „ All ambulance services within a specific region should use a similar reporting form that can be quickly and easily be interpreted by receiving nurses and physicians. „ flow sheets „ uniform data „ NEMSIS/EMSTARS
  24. 24. Disaster Planning The EMS system is an integral element of disaster preparedness and planning. „ Important role in initial response and transportation „ Establish a regional disaster preparedness plan in coordination with public safety agencies, government and medical community ‚ Disaster management, communication, treatment and destination of casualties „ Periodic disaster drills „ MCIs „ Hazmat
  25. 25. Medical Direction The process by which a dedicated physician(s) guides and oversees the patient care that is provided by an EMS system. Why do paramedics, who are licensed by the state, need a medical director or physician advisor?
  26. 26. On-line Medical Direction (OLMD) a.k.a. direct medical control, on-line medical command, or real-time medical control. „ Direct medical communication to personnel in the field. ‚ in person ‚ radio ‚ phone communication • landline (traditional telephone) • cellular
  27. 27. Off-line Medical Control „ Responsibility of the service medical director 2. Development and implementation of protocols and standing orders 3. Development of medical accountability (QA) 4. Development of ongoing education ‚ initial and recertifying training programs. „ Physicians must remember that they have the ultimate responsibility for the overall quality of prehospital medical care.
  28. 28. Qualifications of an EMS Medical Director „ Licensed physician with interest, experience, and knowledge in emergency medicine and prehospital care. „ Preferable if full-time, practicing, emergency physician at the lead hospital for the EMS system, with additional training and experience in EMS.
  29. 29. Medical Basis for EMS
  30. 30. Emergency Cardiac Care ALS saves lives after sudden cardiac arrest. „ The number of lives saved and the cost are debated. Without treatment at the scene, the survival rate of out-of- hospital cardiac arrest is virtually zero. Seattle and King Count, Washington ƒ 26% patients successfully resuscitated from out-of-hospital cardiac arrest. New York City ƒ 1.4% overall survival Outcome of out-of-hospital cardiac arrest in New York City. The Pre-Hospital Arrest Survival Evaluation (PHASE) study. JAMA 1994 Mar (Lombardi, Gallagher, and Gennis)
  31. 31. Hypothermia „ Recommended for witnessed cardiac arrest (Vtach, Vfib) with spontaneous return of circulation „ Administer as soon as possible, i.e, pre-hospital with ice packs to groin, axillae, and neck Howes et al. "Evidence for the use of hypothermia after cardiac arrest." CJEM 2006;8(2):109-15
  32. 32. Minimal Interruption of CPR „ MICR = initial series of 200 uninterrupted chest compressions, rhythm analysis with single shock, then 200 post-shock compressions before pulse check or rhythm-reanalysis; also done before admin of epi, intubation „ Shown to improve survival in out-of- hospital cardiac arrest Bobrow et al. “Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest.” JAMA 299(10)1158-1165.
  33. 33. Improve Survival Shorten interval between collapse and defibrillation. Local system must optimize the “chain of survival” ‚ early access ‚ early CPR ‚ early defibrillation ‚ early ALS „ First responders „ AEDs
  34. 34. Pilot programs Jim Alexander - Security officer Las Vegas security officer saves two lives in less than one year U.S. Air Force retiree Jim Alexander works as a security officer at Stardust Resort and Casino in Las Vegas. In less than one year, Alexander saved the lives of two casino guests: one in September 1997 and another in August 1998.
  35. 35. Trauma Care Delivery of critically injured trauma patients to trauma centers saves lives. Controversial: IV on scene (field) vs. en route Houston: no IVF in Prehospital or E.R. for hypotensive victims of penetrating truncal trauma.
  36. 36. EMS For Children „ Leadership in the area of injury and illness prevention „ Leadership in local, regional, and state EMS and EMSC systems by involvement in the provision of medical direction (oversight), education of providers, quality improvement, and legislative advocacy „ Collaboration with other physicians and health care professionals to enhance the medical home for children, including referral to primary care, specialized care, and rehabilitation services „ Research in the design and function of EMS systems, education of providers, out-of-hospital and emergency care interventions, and outcomes of emergency care „ Expertise for and collaboration with the National EMSC Program (Maternal and Child Health Bureau in collaboration with the National Highway Traffic Safety Administration)
  37. 37. “The Chain of Survival” In 1990, the American Heart Association introduced a treatment model for victims of sudden cardiac arrest called the Chain of Survival. It outlines the specific sequence of events that need to happen for a victim to survive and recover from sudden cardiac arrest.
  38. 38. The Chain of Survival „ Early Access: Someone suspects or determines the victim is in sudden cardiac arrest and calls for help „ Early CPR: Someone trained in CPR keeps the victim’s blood flowing until defibrillation can begin „ Early Defibrillation: Someone trained in defibrillation shocks the victim as quickly as possible „ Early Advanced Care: Medical personnel provide advanced cardiac care which can include airway support, medications, and hospital services
  39. 39. Defibrillators Automated external defibrillators (AEDs) „ analyze the patient’s rhythm, determine whether a defibrillatory shock is indicated, charge the capacitors, and then inform the operator that a shock is advised. „ defibrillate only for ventricular fibrillation and very fast wide QRS complex tachycardias (usually over 180/bpm) „ used only in pulses and apneic patients.
  40. 40. Defibrillators Physio Control Life Pack 12 Zoll “M” Series HP CodeMaster 100
  41. 41. Automated External Defibrillators Physio-Control Laerdal HeartStart LIFEPAK 500
  42. 42. New CPR Guidelines „ Current AHA/ACC ACLS guidelines for chest compression to breath ratio for single provider = 30:2 (vs. 15:2) „ No pulse checks for layperson
  43. 43. Basic Airway Devices „ Oropharyngeal airways (OPA) „ Nasopharyngeal airways (NPA) „ Bag-valve-mask ventilation (BVM) „ Pulmonary Resuscitator
  44. 44. Advanced Airway Devices „ Endotracheal tubes and blades „ End-tidal CO2 detectors (ETCO2) „ Pulse-Oximeter „ Laryngeal Mask Airway (LMA) „ Esophageal Gastric Tube Airway (EGTA) „ Esophageal Intubation Detector „ Esophageal Obturator Airway (EOA) „ Blind insertion ƒ Pharyngeotracheal Lumen Airway (PTL) ƒ Esophageal-Trachea Combitube (ETC) ƒ King Tube „ McGill forceps „ Cricothyrotomy equipment
  45. 45. Vascular Access Equipment „ Paramedics are very adept at placing IV’s „ IV access should not prolong scene times in a trauma patient, especially when “Load and Go” criteria are present
  46. 46. Spinal Immobilization ABC’s The preservation of integrity of the spinal column is of paramount importance in the field. „ C-Spine stabilization and airway assessment are performed simultaneously. „ Manual stabilization of the neck is not released until the patient has been transferred and securely strapped to a board.
  47. 47. Spinal Immobilization ABC’s Odontoid fracture & Atlantoaxial dislocation
  48. 48. Air Medical Transport Association of Air Medical Services (AAMS) Domestic: 362 air medical providers International 23 air medical providers Hospital(s) based „ Helicopter cost: $1-5 million • annual operating cost: $2 million Patients transported „ 827 per program 1997 - survey of 126 United States air medical programs
  49. 49. Clinical Use of Helicopters Fast ambulances 125-175 mph 150-200 mile range Two major types of helicopter missions (1) Trauma/medical scene responses (30%) (2) Interfacility transfers (70%)
  50. 50. Rotor-wing aircraft Advantages „ Can be based at a hospital or another location near your service area. „ Do not require a runway for takeoff and landing. „ Capable of landing in relatively small and secluded areas. „ Usually ready for takeoff in a matter of minutes.
  51. 51. Jacksonville Fire Rescue Ambulance Safety
  52. 52. Future of EMS „ EMS will represent the intersection of public safety, public health, and health care systems. „ EMS will continue to be diverse at the local level. „ As a component of health care systems, EMS will be influenced significantly by their continuing evolution. „ There will be increasing need for information regarding EMS systems and outcomes. „ It will be necessary to continue to make some EMS system-related decisions on the basis of limited information. „ The media will continue to influence the public’s perception of EMS. „ Federal funding/financial resources will be decreasing. „ To make good decisions, public policy makers will need to be well-informed about EMS issues. NHTSA agenda guidelines: